Development, successes, and potential pitfalls of multidisciplinary chronic disease management clinics in a family health team: a qualitative study

Background The creation of Family Health Teams in Ontario was intended to reconfigure primary care services to better meet the needs of an aging population, an increasing proportion of which is affected by frailty and multimorbidity. However, evaluations of family health teams have yielded mixed results. Methods We conducted interviews with 22 health professionals affiliated or working with a well-established family health team in Southwest Ontario to understand how it approached the development of interprofessional chronic disease management programs, including successes and areas for improvement. Results Qualitative analysis of the transcripts identified two primary themes: [1] Interprofessional team building and [2] Inadvertent creation of silos. Within the first theme, two subthemes were identified: (a) collegial learning and (b) informal and electronic communication. Conclusion Emphasis on collegiality among professionals, rather than on more traditional hierarchical relationships and common workspaces, created opportunities for better informal communication and shared learning and hence better care for patients. However, formal communication and process structures are required to optimize the deployment, engagement, and professional development of clinical resources to better support chronic disease management and to avoid internal care fragmentation for more complex patients with clustered chronic conditions. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-023-02073-x.

The goal of these individual, semi-structured interviews is to gather information on the physicians' perspectives about access to Chronic Disease Prevention and Management (CDPM) clinics, the impact that these clinics have on patients' health, resources, and achieving balance, in terms of the distribution of internal resources, communication with clinic staff, and potential conflicts or disagreements with non-lead/specialty clinic physician(s). Their perspectives on other health care professionals' roles and role clarity, learning, support needs, and integration with external specialists or other programs will also be discussed. Lastly, their comfort level with managing chronic conditions, and patients with chronic conditions in an interprofessional, primary care setting will be discussed. The guide may require some modification based on data collected during preceding phases of the intervention.

Instructions:
Start with overview of study and objectives of the interviews. Explain consent and audio tape procedures.
Introduction: There are many concerns that need to be addressed in order to better manage and care for individuals with chronic conditions. The SOFHT is a primary care provider who has several CDPM clinics. The goal of the study is to conduct an in-depth case study of the CDPM clinics. We would like to hear from you about your perspective of these clinics.
Start voice recorder (state date and interview number).

Interview Questions
I would like to discuss some of your beliefs and perspectives to better understand your view on the SOFHT and CDPM clinics. I will ask questions related to several topics to see how important they are to you. Note: The goal of these individual, semi-structured interviews is to gather information on these individuals' perspectives about their clinical role and enactment, as well as how their role is perceived by other team members. Participants will be asked about their potential to expand their role and the barriers that they may face when doing so. Lastly, participants will be asked how comfortable they are with managing chronic conditions. The guide may require some modification based on data collected during preceding phases of the intervention.

Instructions:
Start with overview of study and objectives of interviews. Explain consent and audio tape procedures.
Introduction: There are many concerns that need to be addressed in order to better manage and care for individuals with chronic conditions. The SOFHT is a primary care provider who has several Chronic Disease Prevention and Management (CDPM) clinics. The goal of the study is to conduct an in-depth case study of the CDPM clinics. We would like to hear from you about your perspectives in regards to these clinics.
Start voice recorder (state date and interview number).

Interview Questions
I would like to discuss some of your beliefs and perspectives to better understand your view on the SOFHT and CDPM clinics. I will ask questions related to several topics to see how important they are to you. The goal of these individual, semi-structured interviews is to gather information on the suitability and shortcomings for current electronic medical record platforms, regarding data collection and quality assurance. This will include either embedding quality indicators for various programs or an interRAI-based solution that, with programming, could facilitate more integrated information capture and produce derivative outputs such as risk scores, outcome scales, other quality indicators and case-mix data. The guide may require some modification based on data collected during preceding phases of the intervention.

Instructions:
Start with overview of study and objectives of interviews. Explain consent and audio tape procedures.
Introduction: There are many concerns that need to be addressed in order to better manage and care for individuals who have complex, chronic conditions. The SOFHT is a primary care provider who has several Chronic Disease Prevention and Management (CDPM) clinics. The goal of the study is to conduct an in-depth case study of the CDPM clinics. We would like to hear from you about the information technology issues that exist at the SOFHT.
Start voice recorder (state date and interview number).

Interview Questions
I would like to discuss some of your beliefs and perspectives to better understand your view on the SOFHT and CDPM clinics. I will ask questions related to several topics to see how important they are to you. Facilitation: 11. What are some shortcomings within the current electronic medical record platforms, in terms of data collection and quality assurance? a) How could these be changed in order to overcome them? b) Out of all the shortcomings that currently exist in regards to the electronic medical records platforms, what do you think needs attention first? Probes: Why? How would you make these changes?
12. Think about the current electronic medical record platforms. a) Which quality indicators do you think would be the most important to focus on? Probes: Why? b) How would you embed quality indicators into the platforms for the various CDPM clinics? c) How would you tackle the differences in quality indicators needed for the varying CDPM clinics?
13. Think about the electronic medical records platforms. a) How would you implement interRAI instruments? b) What could be potential benefits to this? What could be potential risks?
14. What else do you think can be changed in regards to the SOFHT and/or CDPM clinics? a) What do you think will lead to better primary care of patients with chronic diseases? b) How can this be implemented within the SOFHT?
Closing notes I would like to thank you for your input and perspective. Are there any other comments you would like to make or relevant stories you would like to share?
Thank you.

APPENDIX K: RESEARCHER INTERVIEW GUIDE FOR SATELLITE HCPs
Participant ID: Date: Data point: Recorder (RA): Note: The goal of these individual, semi-structured interviews is to gather information on these physicians' perspectives in terms of access and effectiveness of the clinics that are given off-site. The potential downfalls and problems related to communication and shared care will be discussed as well as the potential benefits compared to the usual approaches. They will also discuss perspectives on other health care professionals' roles and role clarity, improvements, and comfort level with managing complex conditions. The guide may require some modification based on data collected during preceding phases of the intervention.

Instructions:
Start with overview of the study and objectives of the interviews. Explain consent and audio tape procedures.
Introduction: There are many concerns that need to be addressed in order to better manage and care for individuals who have complex, chronic conditions. The SOFHT is a primary care provider who has several Chronic Disease Prevention and Management (CDPM) clinics. The goal of the study is to conduct an in-depth case study of the CDPM clinics. We would like to hear from you about your personal perspectives regarding the SOFHT and CDPM clinics.
Start voice recorder (state date and interview number).

Interview Questions
I would like to discuss some of your beliefs and perspectives to better understand your view on the SOFHT and CDPM clinics. I will ask questions related to several topics to see how important they are to you. 14. What can be changed in regards to the SOFHT and CDPM clinics? a) What do you think will improve primary care of patients with chronic diseases? b) How can that be implemented within the SOFHT?
Closing notes I would like to thank you for your input and perspective. Are there any other comments you would like to make or relevant stories you would like to share?
Thank you.